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Holistic Lifestyle Intake Form

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*All of the information you share will remain confidential.

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Question 1 of 84

What is your primary intention for completing this intake?

Mental Body

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*All of the information you share will remain confidential.

Question 3 of 84

What do you feel are your general strengths?

Question 4 of 84

What do you feel are your general weaknesses?

Question 5 of 84

What outcome would make you feel ecstatic if you achieved it?

Question 6 of 84

Do you struggle with any of these schizophrenia, bi-polar, major depression or serious suicidal thoughts? If yes, please describe.

Physical Body

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*All of the information you share will remain confidential.

Question 8 of 84

Are you confident in your body? In what ways?

Question 9 of 84

Do you feel safe in your body?

Question 10 of 84

Do you trust your body’s intuition?

Question 11 of 84

Have you ever suffered a head or other serious injury?

Question 12 of 84

What are other significant medical problems that you have had in the past and/or that you are experiencing now?

Question 13 of 84

Do you experience regular pain in your body?

Question 14 of 84

Do you recognize any consistently tight/contracted areas of your body? If so, where and please list any triggers that you can identify that lead to the contraction(s).

Question 15 of 84

In general, how would you rate your physical health?

A

1 - Very unhealthy

B

2

C

3

D

4

E

5 - Balanced

F

6

G

7

H

8

I

9

J

10 - Very healthy

Question 16 of 84

If you don't currently rate your physical health at a 7, what would make it a 7?

Question 17 of 84

In general, how would you rate the level of body awareness you have?

A

1 - No awareness

B

2

C

3

D

4

E

5 - Balanced

F

6

G

7

H

8

I

9

J

10 - Very aware

Question 18 of 84

If you don't currently rate your body awareness at a 7, what would make it a 7?

Question 19 of 84

Describe your current sleeping patterns. When do you sleep? How many hours per 24 hours? Do you sleep straight through, or do you wake during the time you would like to be sleeping? If you awaken, when?

Question 20 of 84

Do you feel rested upon waking? 

A

Yes!

B

Sometimes

C

No

D

I prefer not to answer

Question 21 of 84

Do you have any food cravings?

A

Yes!

B

Sometimes

C

No

D

I prefer not to answer

Question 22 of 84

Do you have daily bowel movements in the morning? 

A

Yes!

B

Sometimes

C

No

D

I prefer not to answer

Question 23 of 84

In general, are you eating what you know fuels your body in the best way?

A

Yes!

B

Sometimes

C

No

D

I prefer not to answer

Question 24 of 84

Do you exercise regularly?

A

Yes!

B

Sometimes

C

No

D

I prefer not to answer

Question 25 of 84

Do you know if your Mother had birth trauma or if your mother had a cesarean section for your birth? Did your mother go through any major life transitions while you were in the womb (i.e. war, natural disaster, marriage issues/dysfunctional relationship,etc)?

Spiritual Body

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*All of the information you share will remain confidential.

Question 27 of 84

What is your greatest challenge right now in life, and what is its potential?

Question 28 of 84

What do you think your form of genius is? What are you exceptional at (work or life-related?)

Question 29 of 84

How do you define God? 

Question 30 of 84

 

In what areas of your life are you not free? (i.e. money, sexuality, power, relationships, etc.). Please briefly describe. 

Question 31 of 84

What do you want to embody more of?

Question 32 of 84

Do you have regular meditation or spiritual practice?

A

Yes!

B

No

C

I prefer not to answer

5 Element Energetic Psychology Assessment

1/5 Wood Element - Liver

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*All of the information you share will remain confidential.

Question 34 of 84

Do you feel you have strong boundaries? 

A

1 - Never

B

5 - Sometimes

C

7 - Often

D

10 - Constant

E

I prefer not to answer

Question 35 of 84

Do you feel you can express yourself truthfully?

A

1 - Never

B

5 - Sometimes

C

7 - Often

D

10 - Constant

E

I prefer not to answer

Question 36 of 84

Do you feel compassionate towards yourself?

A

1 - Never

B

5 - Sometimes

C

7 - Often

D

10 - Constant

E

I prefer not to answer

Question 37 of 84

Do you project anger onto others when you are upset?

A

1 - Never

B

5 - Sometimes

C

7 - Often

D

10 - Constant

E

I prefer not to answer

5 Element Energetic Psychology Assessment

2/5 Fire Element - Heart

Feel free to skip any question you do not feel comfortable answering with the understanding that the more information I have, the better I can serve you.

*All of the information you share will remain confidential.

Question 39 of 84

Do you feel you have unmet expectations that bring you down?

A

1 - Never

B

5 - Sometimes

C

7 - Often

D

10 - Constant

E

I prefer not to answer

Question 40 of 84

Do you feel joyful in your day?

A

1 - Never

B

5 - Sometimes

C

7 - Often

D

10 - Constant

E

I prefer not to answer

Question 41 of 84

Do you feel passion and purpose in your day?

A

1 - Never

B

5 - Sometimes

C

7 - Often

D

10 - Constant

E

I prefer not to answer

Question 42 of 84

Are you able to receive gratitude from others easily?

A

1 - Never

B

5 - Sometimes

C

7 - Often

D

10 - Constant

E

I prefer not to answer

5 Element Energetic Psychology Assessment

3/5 Earth Element - Spleen

Feel free to skip any question you do not feel comfortable answering with the understanding that the more information I have, the better I can serve you.

Question 44 of 84

Do you feel safe in your body?

A

1 - Never

B

5 - Sometimes

C

7 - Often

D

10 - Constant

E

I prefer not to answer

Question 45 of 84

Do you trust that God or a higher power supports you?

A

1 - Never

B

5 - Sometimes

C

7 - Often

D

10 - Constant

E

I prefer not to answer

Question 46 of 84

Do you doubt yourself?

A

1 - Never

B

5 - Sometimes

C

7 - Often

D

10 - Constant

E

I prefer not to answer

Question 47 of 84

Do you give yourself time to integrate and reflect after challenging events in life?

A

1 - Never

B

5 - Sometimes

C

7 - Often

D

10 - Constant

E

I prefer not to answer

5 Element Energetic Psychology Assessment

Metal Element - Lungs

Feel free to skip any question you do not feel comfortable answering with the understanding that the more information I have, the better I can serve you.

Question 49 of 84

Do you feel safe to cry when needed?

A

1 - Never

B

5 - Sometimes

C

7 - Often

D

10 - Constant

E

I prefer not to answer

Question 50 of 84

Do you feel inspired?

A

1 - Never

B

5 - Sometimes

C

7 - Often

D

10 - Constant

E

I prefer not to answer

Question 51 of 84

Do you feel self-honor and courage?

A

1 - Never

B

5 - Sometimes

C

7 - Often

D

10 - Constant

E

I prefer not to answer

Question 52 of 84

Do you feel heaviness on your chest or shoulders?

A

1 - Never

B

5 - Sometimes

C

7 - Often

D

10 - Constant

E

I prefer not to answer

5 Element Energetic Psychology Assessment

Metal Element - Lungs

Feel free to skip any question you do not feel comfortable answering with the understanding that the more information I have, the better I can serve you.

Question 54 of 84

Are you afraid of making a mistake?

A

1 - Never

B

5 - Sometimes

C

7 - Often

D

10 - Constant

E

I prefer not to answer

Question 55 of 84

Do you have a strong willpower to get things done when needed?

A

1 - Never

B

5 - Sometimes

C

7 - Often

D

10 - Constant

E

I prefer not to answer

Question 56 of 84

Do you experience depression seasonally?

A

1 - Never

B

5 - Sometimes

C

7 - Often

D

10 - Constant

E

I prefer not to answer

Question 57 of 84

Do you feel supported by your family?

A

1 - Never

B

5 - Sometimes

C

7 - Often

D

10 - Constant

E

I prefer not to answer

Question 58 of 84

Do you feel a connection to your Ancestors? Please describe

Glands/Chakra Questions

Feel free to skip any question you do not feel comfortable answering with the understanding that the more information I have, the better I can serve you.

*All of the information you share will remain confidential.

Question 60 of 84

Do you feel financially secure?

A

1 - Low

B

5 - Medium

C

10 - High

D

I prefer not to answer

Question 61 of 84

Does your home/household feel safe?

A

1 - Low

B

5 - Medium

C

10 - High

D

I prefer to not answer

Question 62 of 84

Do you feel connected to other people?

A

1 - Low

B

5 - Medium

C

10 - High

D

I prefer not to answer

Question 63 of 84

Do you feel in touch with intimacy and your sexuality?

A

1 - Low

B

5 - Medium

C

10 - High

D

I prefer not to answer

Question 64 of 84

Do you feel connected to your creativity? 

A

1 - Low

B

5 - Medium

C

10 - High

D

I prefer not to answer

Question 65 of 84

Do you feel you have strong willpower?

A

1 - Low

B

5 - Medium

C

10 - High

D

I prefer not to answer

Question 66 of 84

Are you able to set clear boundaries and express yourself authentically?

A

1 - Low

B

5 - Medium

C

10 - High

D

I prefer not to answer

Question 67 of 84

How honest are you with yourself?

A

1 - Low

B

5 - Medium

C

10 - High

D

I prefer not to answer

Question 68 of 84

Are you able to access gratitude and appreciation regularly?

A

1 - Low

B

5 - Medium

C

10 - High

D

I prefer not to answer

Question 69 of 84

Are you connected to your soul purpose?

A

1 - Low

B

5 - Medium

C

10 - High

D

I prefer not to answer

Question 70 of 84

Do you play and experience joy weekly?

A

1 - Low

B

5 - Medium

C

10 - High

D

I prefer not to answer

Question 71 of 84

Are you able to speak with confidence? 

A

1 - Low

B

5 - Medium

C

10 - High

D

I prefer not to answer

Question 72 of 84

Are you able to express your creativity out in the world? 

A

1 - Low

B

5 - Medium

C

10 - High

D

I prefer not to answer

Question 73 of 84

Does your mind feel clear and focused?

A

1 - Low

B

5 - Medium

C

10 - High

D

I prefer not to answer

Question 74 of 84

Are you able to see colors or lights in your spiritual practice?

A

1 - Low

B

5 - Medium

C

10 - High

D

I prefer not to answer

Question 75 of 84

Do you feel connected to God or Higher Power? 

A

1 - Low

B

5 - Medium

C

10 - High

D

I prefer not to answer

Question 76 of 84

Do you feel supported and guided by a Higher Power?

A

1 - Low

B

5 - Medium

C

10 - High

D

I prefer not to answer

Emotional Body

Feel free to skip any question you do not feel comfortable answering with the understanding that the more information I have, the better I can serve you.

*All of the information you share will remain confidential.

Question 78 of 84

Can you look in your eyes in the mirror and honestly say, “I love you” to yourself?  

A

Yes!

B

Sometimes

C

Never

D

I prefer not to answer

Question 79 of 84

How do you generally respond to stressful situations and other problems that arise in your life?

Question 80 of 84

Rate your level of Stress or Anxiety On a scale of 1-10.

A

1 - No stress

B

3 - Sometimes stressed

C

7 - Often Stressed

D

10 - Constant Stress

E

I prefer not to answer

Question 81 of 84

What emotions do you feel most strongly? 

Question 82 of 84

What are the ways you care for and comfort yourself when you feel distressed? 

Question 83 of 84

How do you feel about yourself (self-esteem/confidence)? On a scale of 1-10.

A

1 - Terrible

B

3 - Low

C

5 - Balanced

D

7 - OKAY

E

10 - Amazing

F

I prefer to not answer

Question 84 of 84

What are your current self-care practices? List daily and/or weekly practices.

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